Master Denial Code136: Ensure Compliance with Payer Coverage Rules.

Denial code 136, indicating “Failure to follow prior payer’s coverage rules,” is a frequent challenge in medical billing that can impact your practice’s revenue significantly. This denial code is commonly associated with Group Code OA, used when claims are submitted to a secondary payer. Avoiding these denials requires a clear understanding of the primary payer’s coverage guidelines to ensure compliance and smooth revenue cycles.

Common Reasons for Denial Code 136

1. Lack of Coverage Verification: Failing to confirm the patient’s primary payer coverage leads to submission errors and denial risks.
2. Incomplete or Inaccurate Documentation: Documenting the services provided and prior payer coverage accurately is essential for claim approval.
3. Misinterpretation of Coverage Rules: Misunderstanding coverage rules can lead to non-covered claim submissions.
4. Out-of-Network Services: If the primary payer considers the provider out-of-network, secondary payers may also deny the claim.
5. Failure to Appeal or Resubmit: When denials occur, promptly appealing or resubmitting with the right information is essential.
6. Benefit Limits Exceeded: When services exceed primary payer limits, the secondary payer is unlikely to cover them.
7. Non-Covered Services: If the primary payer does not cover specific services, secondary payers may follow suit.

Best Practices to Prevent Denial Code 136

1. Thorough Review of EOB/ERA: Analyze Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) statements to understand denial reasons and avoid similar errors in future claims.
2. Verify Patient Coverage: Regularly confirm the patient’s coverage with the primary payer, especially for frequently used services.
3. Document All Communications: Maintain records of all correspondence with primary payers, creating a reference for future claims.
4. Submit Complete Information: Ensure that all claims include detailed information about primary payer coverage and provided services.
5. Build Strong Relationships with Payers: Positive relations with both payers and patients help resolve coverage discrepancies more efficiently.
6. Implement a Denial Management System: Use a robust denial tracking system to quickly address and resolve issues.
7. Utilize Technology: Leverage software tools to streamline claims submission and automate aspects of the appeals process.

Conclusion
Denial code 136 can be a substantial roadblock for healthcare practices, but understanding its causes and implementing preventive strategies can mitigate its financial impact. By following coverage guidelines, verifying patient eligibility, and maintaining comprehensive documentation, your practice can reduce the occurrence of these denials and optimize revenue cycles.

Get Expert Help
If your practice is facing challenges with denial code 136 or other RCM obstacles, Claims Med is here to help. Contact us today to discover how our solutions can streamline your billing processes, reduce denials, and improve overall financial performance.